KNEE IMPAIRMENT OF

DAVID H. ROBERTSON · 2026 · Case ID: 26003526

DENIED

Summary

The Veteran, who served in the United States Air Force from March 1967 to March 1971, died in June 2017. His surviving spouse was substituted in his appeal for service connection benefits for bilateral knee disabilities, including osteoarthritis. The Veteran claimed he injured his knees during service when he fell carrying heavy test gear, experiencing pain during and after service. He also contended the knee disabilities were secondary to a service-connected back condition. The Board reviewed extensive evidence, including service treatment records (STRs), multiple VA medical opinions, and private medical opinions. The STRs showed normal knee evaluations during service and no complaints or treatment for knee issues. Post-service treatment for knee pain did not begin until October 2009, with a diagnosis of osteoarthritis in April 2017. Multiple VA examiners opined that the bilateral knee osteoarthritis was less likely than not related to service, citing the lack of in-service complaints, the long delay before seeking treatment, and the likelihood of degenerative changes due to aging, obesity, and post-service occupational demands. Private opinions suggesting a link to service were given minimal weight due to a failure to adequately address the lack of in-service treatment and the significant post-service delay. The Board found the VA opinions more probative, concluding that the evidence did not establish service connection for the bilateral knee disabilities. The benefit-of-the-doubt rule was not applied as the evidence was not in approximate balance. Service connection for both left and right knee disabilities was denied.

Rationale

Service treatment records normal for left knee.; No in-service complaints or treatment for left knee.; Post-service treatment began over 40 years after service.; VA examiners opined less likely than not related to service.; Private opinions given minimal weight due to lack of in-service nexus and post-service delay.

Service Branch

AIR FORCE

Special Benefit

NO SPECIAL BENEFIT

Docket No.

14-29 189

Full Decision Text

Citation Nr: 26003526
Decision Date: 03/18/26 Archive Date: 03/18/26

DOCKET NO. 14-29 189
DATE: March 18, 2026

ORDER

Entitlement to service connection for a left knee disability, to include osteoarthritis, for substitution purposes, is denied.

Entitlement to service connection for a right knee disability, to include osteoarthritis, for substitution purposes, is denied.

FINDINGS OF FACT

1. The Veteran's left knee disability, to include osteoarthritis is not etiologically related to an in-service injury or disease, arthritis of the left knee did not manifest to a compensable degree within the applicable presumptive period, and the left knee disability was not caused or aggravated by a service-connected disability.

2. The Veteran's right knee disability, to include osteoarthritis is not etiologically related to an in-service injury or disease, arthritis of the right knee did not manifest to a compensable degree within the applicable presumptive period, and the right knee disability was not caused or aggravated by a service-connected disability.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a left knee disability, to include osteoarthritis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

2. The criteria for entitlement to service connection for a right knee disability, to include osteoarthritis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Air Force from March 1967 to March 1971; he died in June 2017. The Appellant is his surviving spouse. She has been substituted in the Veteran's appeal for service connection benefits.

This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

In November 2018, the Board denied entitlement to service connection for a left knee disability and remanded the right knee disability claim for further development. The Appellant appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court), which granted an August 2019 Joint Motion for Partial Remand (JMPR). The Court's August 2019 Order vacated the Board's November 2018 decision and remanded the matter to the Board for readjudication consistent with the terms of the JMPR.

In January 2021 and October 2023, the Appellant testified at a hearing before a Veterans Law Judge (VLJ) who is no longer employed by the Board. A transcript of both hearings has been associated with the claims file. In a January 2026 letter, the Board notified the Appellant that the VLJ who conducted her hearing was not available to participate in her appeal. That letter offered the Appellant the option of electing a new hearing before a different VLJ. The Appellant (through her representative) elected not to have another hearing.

In June 2022, April 2024, and January 2025, these matters were remanded by the Board for further development by the agency of original jurisdiction (AOJ).

As noted, this case returns to the Board following a remand to the AOJ in January 2025. Specifically, the Board directed the AOJ to obtain an addendum VA opinions with regard to the Veteran's claims. On remand, the AOJ obtained such addendum opinions. Thus, the AOJ substantially complied with the January 2025 Board remand directives. See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The case has now been returned to the Board for appellate action.

The Veteran submitted a private medical opinion after the issuance of the May 2025 supplemental statement of the case (SSOC). The Appellant's representative has waived initial AOJ consideration of the evidence. 38 C.F.R. § 20.1305. Therefore, there is no prejudice to the Veteran and accordingly, the Board will proceed with adjudication on the merits below.

Service Connection - Left and Right Knee Disabilities

Prior to his death, the
Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The case has now been returned to the Board for appellate action.

Service Connection - Left and Right Knee Disabilities

Prior to his death, the Veteran testified that he injured his knees during service when he fell while carrying heavy test gear up a set of stairs in a tunnel and struck his knees. He noted that he fell on both knees and his left knee bore the initial brunt of the fall. He reported that he had pain during service following the incident and he continued to have pain since that time. Additionally, the Appellant asserted that the left and right knee disabilities were secondary to a service-connected back disability.

As an initial matter, a private clinician suggested a link between the Veteran's knee disabilities and exposure to herbicides. However, in an April 2023 Memorandum, the AOJ indicated that the Veteran did not have boots on the ground in any location where presumptive exposure to herbicides has been conceded. Therefore, the Veteran is not presumed to have been exposed to herbicides during service, and the Board will not address whether a bilateral knee disability was due to herbicide exposure.

A review of the Veteran's service treatment reports (STRs) reveals a normal clinical evaluation of the lower extremities at the May 1966 preinduction examination. The Veteran denied trick or locked knee on a report of medical history form prepared in conjunction with the examination. The Veteran was noted to have fractured his leg at age one. The records do not reveal any complaints, findings, or treatment for any knee injuries or complaints. The Veteran's February 1971 separation examination revealed a normal clinical evaluation of the lower extremities. The Veteran denied trick or locked knee on a report of medical history form. The examiner noted a fractured right leg in childhood, no deformity, completed recovery, treated, no complication, and no sequelae.

Post service VA outpatient treatment reports do not reveal treatment for the knees until he reports pain in both knees in October 2009. He was assessed with knee osteoarthritis in April 2017.

At a May 2017 VA knee examination, the Veteran reported that he had not sought treatment for either knee until recently when was seen for right knee pain and was advised he had degeneration of the knee per x-rays. He reported that he had sharp, achy pain in both knees and it switched sides. Following a clinical evaluation, the examiner stated that a left knee disability had not been diagnosed or treated. However, she found that the Veteran had limited range of motion in his left knee. The examiner explained that she did not know why the Veteran had limited motion given the Veteran's normal lower extremity strength, sensation, and reflexes. The examiner diagnosed the Veteran with degenerative arthritis of the right knee and opined that the right knee disability was less likely than not incurred in or caused by service. The examiner's rationale was that mild degenerative changes of the right knee were not diagnosed until fifty years after military discharge. The examiner indicated that the degenerative changes were most likely due to aging although a history of traumatic injury of the right leg (as a child being hit by a car fracturing the right leg) is known to raise the chances of developing joint problems seven-fold. The examiner also opined that claimed condition clearly and unmistakably existed prior to service and was not aggravated by service. However, the Veteran was presumed sound at his entrance to service (as noted, clinical evaluation of the bilateral lower extremities was normal at his entrance to service), and the appropriate standard is direct service connection and not aggravation of a pre-existing knee disability. 38 U.S.C. § 1111. As such, the opinion regarding aggravation is not probative with regard to the right knee claim.

In March 2019, a VA examiner indicated that she was unable to provide an opinion without resort to speculation as to whether a right knee disability was caused or chronically worsened by a service-connected back disability.

In May 2020, a VA examiner opined that the a knee disability was less likely than not caused or chronically worsened by a service-connected back disability to include an altered gait and/or body mechanics. The examiner's rationale was that knee osteoarthritis is classified as either primary or secondary, depending on its cause. Primary knee osteoarthritis is the result of articular cartilage degeneration without any known reason which is typically thought of as degeneration due to age as well as wear and tear. Secondary knee osteoarthritis is the result of articular cartilage degeneration due to a known reason. The examiner also indicated that since the activity level of patients with chronic low back pain is usually limited, i.e. decreased stride length and walking speed, it is unlikely that either lower extremity would be subjected to greater than normal force since the magnitude of joint force transmission for both lower extremities is related to walking speed and the generation of acceleration forces by the limb segments while walking.

In April 2023, a VA examiner reviewed the claims file and opined that it was less likely than not that a right knee disability was caused by a service-connected back disability. The examiner's rationale was that there is no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis, or shortening of the injured limb resulting in length discrepancy of more than 5 centimeters (cm) so that the individual's gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait. The examiner stated that this level of severity is not supported based on record review, history, or examination. The examiner indicated that it is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it. The examiner also opined that a right knee disability was not aggravated beyond its normal progression by a service-connected back disability. The examiner's rationale was that the medical literature does not support aggravation based on a review of the claims file. The examiner also opined that a right knee disability was not aggravated beyond its normal progression by service-connected tinnitus as tinnitus and the right knee are medically unrelated.

In a January 2024 opinion, R. Sarlay, Jr., M.D., opined that the right and left knee osteoarthritis was at least as likely as not caused by service. Dr. Sarlay cited to medical studies which found that military service places a service member at increased risk for the development of osteoarthritis. He concluded that military service is a known risk for the development of osteoarthritis.

In May 2024 , a VA examiner opined that right and left knee disability was less likely than not incurred in or caused by service. The examiner's rationale was that the STRs were silent for any reference to right knee pain, injury, or disability during service and after service, x-rays obtained at VA in April 2017 revealed osteoarthritis of the bilateral knees and stated that there were symmetrical degenerative changes in both medial joints, most likely normal wear and tear associated with the aging process. The examiner noted that the diagnoses of osteoarthritis came forty-six years after military service. The examiner noted that osteoarthritis, also known as degenerative joint disease, occurs when the cartilage that covers the tops of bones, known as articular cartilage, degenerates or wears down causing swelling, pain, and sometimes the development of osteophytes (bone spurs) when the ends of the two bones rub together. The major contributory factors include advancing age, female sex, joint trauma, obesity, and some genetic factors. The examiner reviewed the claims file and prior medical opinions and noted that the development of osteoarthritis at age 70 would not be considered premature. The examiner acknowledged that the Veteran's knees could have been injured in service despite the lack of in-service treatment, but that injury was resolved based on the lack of documentation in service. Moreover, the Veteran did not seek treatment for the knees until forty-seven years after he left service.

With regard to the left knee, the examiner also opined that the left knee disability was less likely than not caused or aggravated by a service-connected back disability. The examiner's rationale was that there is no clear evidence from a review of the orthoped
female sex, joint trauma, obesity, and some genetic factors. The examiner reviewed the claims file and prior medical opinions and noted that the development of osteoarthritis at age 70 would not be considered premature. The examiner acknowledged that the Veteran's knees could have been injured in service despite the lack of in-service treatment, but that injury was resolved based on the lack of documentation in service. Moreover, the Veteran did not seek treatment for the knees until forty-seven years after he left service.

With regard to the left knee, the examiner also opined that the left knee disability was less likely than not caused or aggravated by a service-connected back disability. The examiner's rationale was that there is no clear evidence from a review of the orthopedic literature to support that an injury to one joint would have any significant impact on another uninjured joint or limb unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis. Any musculoskeletal condition with shortening of the injured limb greater than a 5 cm leg length discrepancy causing a Trendelenburg gait would also have an impact on an unaffected joint. A review of the Veteran's medical records does not reveal this level of alteration in joint function or gait. The use of contralateral body components as a result of avoiding the use of a painful or limited component is a natural biomechanical compensation.

In April 2025, a VA examiner opined that the bilateral knee disability was less likely than not incurred in or caused by service. The examiner included a detailed rationale and indicated that a review of the claims file reveals that the STRs are silent for any complaints, findings, or treatment for the right or left knee and a review of the medical evidence and literature far outweighs the likelihood of claimed right and left knee conditions being incurred in or caused by service. The examiner specifically noted that while Dr. Sarlay indicated that medical literature indicates that there is a link between military service and the development of osteoarthritis of the knees, the Veteran did not seek any treatment for the knees until more than thirty-eight years after he left service when he was advancing in age.

The examiner cited to Up To Date and noted that the Veteran's post-service profession in construction, his obesity, and the length of time before he sought treatment for his knees as the basis for his rationale. The examiner also opined that the bilateral knee disabilities were less likely than not caused by tinnitus as tinnitus is not considered to be anatomically plausible explanation or etiologic risk factor for causation of right and left knee osteoarthritic disability, as osteoarthritis is much more likely to be culmination of multiple inseparable nonservice-related post remote discharge comorbid conditions, including natural progression of osteoarthritic disease process due to aging [also referred to as "degenerative changes," and described as "normal (or usual) wear and tear"], inherited genetics, actual biomechanics of his inherent knee joint anatomy, and lifestyle choices, specifically physical demands and stressors of his self-chosen post separation laboriously strenuous occupational profession of construction remodeling. The examiner further opined that the Veteran's bilateral knee disabilities were less likely than not proximately due to or the result of his service-connected back disability.

The examiner's rationale was that osteoarthritis is much more likely to be the culmination of multiple inseparable nonservice-related post remote discharge comorbid conditions, including natural progression of osteoarthritic disease process due to aging [also referred to as "degenerative changes," and described as "normal (or usual) wear and tear"], inherited genetics, actual biomechanics of his inherent knee joint anatomy, and lifestyle choices, specifically the physical demands and stressors of his self-chosen post separation laboriously strenuous occupational profession of construction remodeling.

Finally, the examiner opined that the bilateral knee disabilities were less likely than not aggravated beyond the natural progression by a service-connected back disability. The examiner's rationale was that osteoarthritis is much more likely to be the culmination of multiple inseparable nonservice-related post remote discharge comorbid conditions, including natural progression of osteoarthritic disease process due to aging [also referred to as "degenerative changes," and described as "normal (or usual) wear and tear"], inherited genetics, actual biomechanics of his inherent knee joint anatomy, and lifestyle choices, specifically physical demands and stressors of his self-chosen post separation laboriously strenuous occupational profession of construction remodeling.

In May 2025 , a VA examiner opined that the bilateral knee disability was less likely than not aggravated by a service-connected back disability. The examiner's rationale was that the STRs were silent for complaints of right and left knee pain, injury or disability during military service, the February 1971 separation examination is silent for right and left knee pain, and the Veteran denied any knee medical and surgical history. Moreover, the first medical evaluation found of record for complaints of knee pain is in March 2017 but the complaints for the right knee and one area of the note states the pain started "Monday night" and the next part of the note states "pain for several years." At an April 2017 orthopedic referral, the Veteran reported pain since military service. However, the physician completed x-rays of both knees and diagnosed osteoarthritis of bilateral knees and noted symmetrical degenerative changes both medial joints most likely normal wear and tear associated with the aging process. The examiner also indicated that pain and stiffness from degenerative disc disease of the spine can lead to reduced physical activity and muscle weakness, which can contribute to knee osteoarthritis and can indirectly contribute to its development or worsening through changes in posture, biomechanics, nerve compression, and muscle weakness.

In August 2025, Dr. Sarlay once again opined that following a review of the claims file, the Veteran's left and right knee osteoarthritis were incurred in or caused by service. The examiner's rationale was that the Veteran conducted repetitive physically demanding work while in service. Further, medical literature shows that in addition to obesity, aging, and physically demanding job such as construction, military service is also a risk factor for the development of osteoarthritis. Dr. Sarlay indicated that which factor is most causative requires consideration of the relative impact of each factor based on clinical and biological criteria. Multifactorial diseases such as osteoarthritis, where multiple risk factors are involved make the process difficult when determining what is most causative. Dr. Sarlay concluded that there is evidence that both service and non-service factors could have caused the Veteran's bilateral knee condition and apportioning which of the multiple factors was more causative is a matter of opinion.

In considering the evidence of record and the applicable laws and regulations, the Board concludes that the Veteran is not entitled to service connection for left and right knee disabilities, to include osteoarthritis.

As an initial matter, the Board notes that the opinions proffered by Dr. Sarlay did not address the fact that the Veteran's bilateral knee disability, diagnosed as osteoarthritis, did not manifest until more than forty years after he left service. He failed to offer any explanation as to how service was a more likely etiology for the knee disabilities as opposed to the other factors noted by multiple VA examiners. As such, the Board finds that the opinions from Dr. Sarlay are entitled to minimal probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

However, the Board finds that the multiple VA examiners' opinions taken together are adequate because the examiners thoroughly reviewed the claims file and discussed the relevant evidence, considered the contentions of the Veteran and the Appellant, and provided thorough supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As such, the VA medical opinions are the most probative evidence of record. Additionally, osteoarthritis of the knees was not present in service or manifest for more than forty years after he left service. 38 C.F.R §§ 3.307, 3.309

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To the extent that the Veteran (prior to his death) and the Appellant believe that the Veteran's bilateral knee disabilities were due to service, neither the Veteran nor the Appellant are competent to provide nexus opinions in this case. The issues are medically complex, as they require knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In short, the Board gives more probative weight to the VA medical opinions of record.

Accordingly, the Board finds that the benefit-of-the
.F.R §§ 3.307, 3.309

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Accordingly, the Board finds that the benefit-of-the-doubt rule is not applicable as the evidence is not in approximate balance, and entitlement to service connection for left and right knee disabilities is not warranted. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

David H. Robertson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. Cryan, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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